Anesthetic considerations for pediatric liver transplantation

Liver transplantation is an established treatment for children with end-stage liver disease, acute liver failure, and selected metabolic and malignant conditions. Small circulating volume, limited thermoregulatory and metabolic reserve, interruption and recovery of hepatic function, and graft-recipient size mismatch affect perioperative care. This narrative review examined how these features inform preoperative assessment, anesthetic preparation, management across the operative phases, and recovery. Cardiopulmonary assessment identified associated anomalies and functional impairment that affect tolerance of induction and reperfusion. Intraoperative management combined assessment of blood loss, vascular tone, and ventricular function with serial evaluation of temperature, electrolyte and glucose levels, and hemostasis. Systemic hemodynamic measurements were interpreted alongside graft-specific inflow and outflow assessment, and fluid responsiveness was distinguished from a clinical need for fluid. Postoperative management included respiratory readiness, unresolved metabolic and circulatory disturbances, renal function, and analgesia. The evidence was interpreted according to population, design, and setting. Pediatric guidelines chiefly addressed candidate evaluation and postoperative care, while much intraoperative evidence came from small observational cohorts or extrapolation from pediatric intensive care and adult transplantation. The recipients with the smallest body size and children with acute liver failure, metabolic disease, or repeat grafts require further adaptation. This review emphasized preparation for predictable disturbances and reassessment after intervention, while avoiding the application of study-specific thresholds or protocols.